The URL can be used to link to this page

Home My WebLink AboutBLD-23-001800 OY:Y`9R Office Use ice /j r' •*�ffj�+ ..� � i Permit# Liles /V 9 OuIl'�l y (� J Amount la.Od \G MATTACM CSE :"I c`3 Permit expires 180 days from ?="'' {issue date 8 t D -d3 - 40 i-a2) EXPRESS BUILDING PERMIT APPLI . 'i s ' c t V V CS TOWN OF YARMOUTH Yarmouth Building Department V:i_l_c-f 05 2Q22 1146 Route 28 South Yarmouth, MA 02664 -G--RTMENT (508) 398-2231 Ext. 1261 BulLp1N _---- CONSTRUCTION ADDRESS: 3t72- (0 1- a-/'SC ASSESSOR'S INFORMATION: _ Map:es Parcel: OWNER: , vend 6 ,1. C_Al, I.2C.;n�— .(o iz.0( S�e�.4 �z!-D' - NAME / RESENT ADDRESS T CONTRACTOR: c/ �v '7 i L/- 4 2 -I,3 tit/ NAME MAILING ADDRESS TEL.# ❑Residential 0 Commercial Est.Cost of Construction$ t v ..DZ y Home Improvement Contractor Lic.# Construction Supervisor Lic.# Wor an's Compensation Insurance: (check one) I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation -Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing ,r1>o Se,r\k,.,1 ‘,,A\\3 *The debris will be disposed of at: yAk,r-N,UNIOntU,-.. Location of acility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revocation of my license and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: /� ` Date: 0c,Owners Signature(or attachment) (�-C z,. Date: IG�U 7- 9 Approved By: Date: /0— BuildingOfffi (or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No The Commonwealth of Massachusetts 11, Department of Industrial Accidents kif 1 Congress Street, Suite 100 Boston, MA 02114-2017 5 www.mass.go v/dia 'Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Please Print Leaibl Name (Business/Organization/Individual): Address: — City/State/Zip: Phone Are you an employer?Check the ap propriate box: I am a employer with employeesType of project(required): (full and/or part-time).* 7. 2.0 I am a sole proprietor or partnership and have no employees working for me in New construction any capacity. [No workers'comp. insurance required.] 8. n Remodeling 3• I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. aSDemolition — 4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 10 Building addion proprietors with no employees. 11. Electrical repatiirs or additions 12.E Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp. insurance.: 13.[]Roof repairs 6.1:We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§1(4),and we have no employees. [No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date . Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00) and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true'and correct. IY\S ianature: Phone#: Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (circle one): Permit/License# 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: